GAINESVILLE, Ga. — U.S. officials released the final safety report for a 2021 nitrogen leak that killed six workers at a Gainesville chicken plant. The report found that the plant had “inadequate emergency preparedness” and the leak was “completely preventable.”
Channel 2 Action News reported on the Jan. 28, 2021 leak at the Foundation Food Group facility in Gainesville.
After the incident, staff from the Occupational Safety and Health Administration (OSHA) and Georgia’s State Fire Marshal’s office worked with Hall County investigators to determine the cause of the leak.
Additional investigators from the U.S. Chemical Safety and Hazard Investigation Board also went to the plant to pinpoint the cause of the accident.
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A recording of the 911 call revealed how a line ruptured and liquid nitrogen poured out and into the plant, killing Jose DeJesus Elias-Cabrera, Corey Alan Murphy, Nelly Perez-Rafael, Saulo Suarez-Bernal, Victor Vellez and Edgar Vera-Garcia.
Five people died inside the plant while another a sixth victim died after being rushed to the hospital.
The victims of the nitrogen leak worked a variety of positions, including as maintenance workers, supervisors, and managers.
Additionally, more than a dozen other workers were injured trying to save the six victims, according to a report by CSB.
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History at the plant was full of past OSHA violations. Channel 2 investigative reporter Nicole Carr showed how the company had been under investigation by OSHA at least three other times since 2017.
In 2019, Channel 2 Action News reported that then-owners Prime Pak had paid a $10,000 fine levied by Georgia’s Environmental Protection Division for not having a filed emergency plan to deal with ammonia.
About two weeks after the incident at the plant in 2021, CSB said unplanned maintenance along the cryogenic freezing system had been done, but did not explicitly link it to the fatalities. However, multiple agencies targeted the cryogenic system for their investigations of the deadly leak.
In July 2021, OSHA released a report on the deadly gas leak, saying the injuries and deaths were “entirely avoidable,” finding that Foundation Food Group, Inc. and Messer, LLC, who maintained the cryogenic system “failed to implement any of the safety procedures necessary to prevent the nitrogen leak” in addition to not equipping workers with knowledge and tools that could have saved their lives.
As previously covered by Channel 2 Action News, federal investigators also reported soon after the leak that there were multiple other safety violations workers faced as they fought to escape the nitrogen leak.
Now, the investigation report by CSB said the incident boiled down to “a series of operational problems with the equipment. Messer returned to the FFG facility on multiple occasions to troubleshoot these operational issues, including problems with belt loading, liquid nitrogen level control, and freezing.”
The report added that the freezer had a manufacturing defect, which was not noticed by its designer, Messer, and which contributed to the single point of failure.
That single point of failure is what set up the fatal incident.
CSB concluded that “the immersion freezer was designed such that the failure of a single level measurement device could defeat both the nitrogen level control system and the emergency interlock intended to stop nitrogen flow to the freezer,” causing the bubbler tube to the freezer to bend during the unplanned maintenance.
“This needless and senseless tragedy was completely preventable. Six people died and four others were seriously injured because of a bent tube and FFG’s failure to have critical monitoring equipment and warning alarms and FFG’s failure to adequately train and equip its employees to respond safely to a liquid nitrogen release,” CSB Chairperson Steve Owens said in a statement.
CSB summarized the report findings as:
- Single Point of Failure. The immersion freezer design included a device called a bubbler tube, which was used to measure the liquid nitrogen level inside the freezer. The bubbler tube was likely bent during maintenance activity, rendering it unable to measure and control the freezer’s liquid nitrogen level. As a result, liquid nitrogen overflowed from the freezer and filled the room with vaporized nitrogen.
- Atmospheric Monitoring and Alarm Systems. There is abundant industry guidance on the importance of atmospheric monitoring when the potential for hazardous atmospheres exists. FFG, however, did not install atmospheric monitoring equipment in the freezer room.
- Emergency Preparedness. FFG did not inform, train, equip, drill, or otherwise prepare its workforce for a release of liquid nitrogen. FFG’s workforce lacked knowledge on the hazards of nitrogen, were unable to recognize an oxygen-deficient atmosphere, and lacked any equipment or Personal Protective Equipment (PPE) that would have enabled safe entry into an oxygen-deficient atmosphere.
- Process Safety Management System. FFG had no documented process safety management policy and allowed the job position responsible for safety management to be vacant for more than a year prior to the incident. The company did not evaluate the process hazards associated with the freezer, lacked written procedures and a management of change process, and did not train its workers on the asphyxiation hazards of liquid nitrogen.
- Product Stewardship. Messer owned the liquid nitrogen bulk storage tanks and the Line 4 immersion-spiral freezer and leased the equipment to FFG. At the time of the incident, Messer had institutional knowledge, experience, policies, and practices for effective product stewardship but applied those practices only to the bulk storage tanks and not to the Line 4 freezer process. Throughout its relationship with FFG, Messer identified issues with FFG’s safety practices and nonconformance to industry guidance, but despite FFG’s unsafe practices Messer continued to supply FFG with liquid nitrogen.
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